The use of expandable metal stents during neoadjuvant therapy as a bridge to esophagectomy for obstructing esophageal cancer

Abstract

Most patients with esophagus cancer present with dysphagia, weight loss and varying degrees of malnutrition which can be exacerbated during neoadjuvant therapy. Conventional approaches to nutritional repletion include surgical feeding tubes for enteral feeds or parenteral nutrition. Expandable metal stents have proven to be safe, effective, and improve quality of life in patients with inoperable, obstructing esophagus cancer but have not been employed when resection is being considered. The objective of this report was to review our initial experience using expandable metal stents to relieve dysphagia in patients with operable esophagus cancer undergoing neoadjuvant therapy. From January 1997 to October 1997, 8 uncovered expandable metal stents (Ultraflex, Boston Scientific Corporation) were placed in seven patients with operable, obstructing esophageal cancer with a mean age of 61 years. Dysphagia score was assessed before and after stent placement (1 for no dysphagia to 5 for complete obstruction). Metal stents were placed prior to initiation of chemotherapy in 6 patients and during chemotherapy in 1. All patients had resectable stage III distal esophageal cancer (adenocarcinoma). All stents were successfully deployed without complications. There was a significant reduction in dysphagia score from 3.1 to 1.1 two weeks post-stent deployment (p<0.05) allowing a soft regular diet without additional nutritional supplementation. Post-procedural complications included bleeding and tumor overgrowth in one patient requiring insertion of a second stent. Six patients underwent successful esophagectomy. The mean interval between stent placement and esophagectomy was 61 days. Moderate periesophageal fibrosis was present but did not prolong operative time or increase surgical complications. This preliminary experience suggests that expandable metal stents are safe and allow prompt return of oral nutritional intake in patients with obstructing esophagus cancer undergoing chemotherapy while awaiting resection. Further studies are necessary to compare the cost effectiveness and quality of life issues using expandable esophageal stent a s a bridge to esophagectomy compared to traditional invasive feeding tubes or TPN.